Provider Demographics
NPI:1225218365
Name:NORTHERN ILLINOIS UNIVERSITY
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS UNIVERSITY
Other - Org Name:TRICOUNTY COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM DEAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRITCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:815-753-6155
Mailing Address - Street 1:21193 MALTA RD
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:IL
Mailing Address - Zip Code:60150-9600
Mailing Address - Country:US
Mailing Address - Phone:815-753-9010
Mailing Address - Fax:815-753-9018
Practice Address - Street 1:21193 MALTA RD
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:IL
Practice Address - Zip Code:60150-9600
Practice Address - Country:US
Practice Address - Phone:815-753-9010
Practice Address - Fax:815-753-9018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL143880Medicare Oscar/Certification